Traumatic brain injury clinical practice guidelines and best practices from the VA state of the art conference

ABSTRACT

Management of symptoms following traumatic brain injury (TBI) can be complex and remains a high priority for Department of Defense (DoD) and Department of Veteran Affairs (VA). Concurrently, awareness of TBI in the public has increased. VA convened a State of the Art (SOTA) Conference to identify priorities for future research and promote best practices for TBI care. Scientific evidence of effective management of symptoms following TBI is expanding, and this evidence has been synthesized into Clinical Practice Guidelines (CPGs) and Clinical Practice Recommendations (CPRs). Knowledge gaps still exist and research efforts to address these gaps should include leveraging large administrative data sets and existing registries to determine effective treatments, investigate compliance of existing clinical care with CPGs and study limitations to determine modifiable vs. non-modifiable core tenants of the evidence-based treatments.

KEYWORDS:

• Clinical practice recommendations
• clinical practice guidelines
• mild traumatic brain injury
• concussion
• post-traumatic stress disorder

Introduction

The Department of Veteran Affairs (VA) hosted a Traumatic Brain Injury (TBI) State of the Art (SOTA) Conference in August 2015, highlighting the state of science in TBI diagnosis and care and identifying priorities for future research and advancement. A session covering TBI Clinical Practice Guidelines (CPGs) and best practices included structured presentations on Department of Defense (DoD) Clinical Recommendations, VA/DoD CPGs, and treatment of TBI and comorbid conditions which are summarized in this manuscript. Followed by an open forum discussion, the goals of the session were to identify research recommendations to advance evidence pertaining to best practices for TBI care of military veterans.

Current TBI clinical care in DoD and VA

A focus on TBI care in DoD and VA is especially germane during the past decade of the US military engagements in overseas war and contingency operations. TBI is also recognized as a major cause of disability and death for US civilians, with Centers for Disease Control and Prevention reporting 2.5 million TBIs in 2010 [1].

Referred to as a ‘signature injury’ [2] of Operation Enduring Freedom/Operation Iraqi Freedom in 2005, this was in recognition of the incidence of brain injuries in service members during deployment. According to DoD incidence tracking of TBI severity, the vast majority (80%) of TBIs in the US service members are clinically graded as mild TBI (mTBI) [3].

Consistent and clinically sound TBI assessments and treatments are critical. Defense and Veterans Brain Injury Center, founded in 1992, is the DoD lead for the TBI Pathway of Care for the military, which includes implementing evidence-based clinical practices and education on TBI, for deployed and in garrison settings, including tracking patient outcomes, educating on TBI clinical care and facilitating delivery of quality care.

Clinical practice recommendations (CPR) and clinical practice guidelines (CPG)

Since 2012, eight TBI CPRs [4], from neuroendocrine dysfunction after TBI to most recently post-traumatic headache management in February 2016, have been published. With algorithmic clinical recommendations for assessing and managing mTBI symptoms as well as standardized patient education fact sheets, providers can use literature reviews, research and expert opinion to educate and advise patients and their family. CPRs incorporate recent literature reviews, consensus statements and expert opinion to guide care but do not necessarily meet the rigour of CPG development.

VA and DoD first published CPGs for mTBI in 2009 with updates published in 2016 [5]. CPGs are developed under a rigorous process including formulation and prioritization of knowledge questions for a systematic review, completion of a systematic review of the literature, and clinical expert panel review and documentation of the guidelines [6].

The mTBI CPGs were designed for patients 18 or older diagnosed with concussion or TBI and ongoing symptoms at least 7 days post-injury. The algorithms within the CPGs are designed to accommodate patients on initial presentation and for management of ongoing symptoms. The CPGs include 23 evidence-based recommendations that utilized the GRADE methodology to assess quality of evidence and determine the strength (i.e. weak or strong) of the recommendation [7]. Recommendations can be for or against the use or timing of a specific intervention or treatment.

CPG mTBI assessment updates

Assessment updates to the CPGs were added based on updated literature review and listed below followed by the strength of the recommendation, which is based on the strength of the evidence [6].

• Recommendation for use of the terms ‘history of mTBI’ or ‘concussion’ and avoid terms ‘brain damage’ or ‘patients with mTBI’: Strength Weak.

• Evaluate individuals identified in post-deployment screening or those individuals who present for care with symptoms or complaints potentially related to head injury: Strength Strong.

• Recommend against the use of routine comprehensive neuropyschological testing for patients identified by post-deployment screenings or who present to care with symptoms or complaints potentially related to head injury: Strength Strong.

• Identify patients by post-deployment screening or who present to care with symptoms or complaints potentially related head injury, recommend against the use of routine comprehensive and focused neuropsychological testing: Strength Strong.

• Recommend against routine referral for speciality care in the majority of patients with mTBI if their symptoms resolved in the early post-acute recovery period as expected: Strength Weak.

• Treatment strategy and outcome prognosis should not be adjusted based on mechanism of injury: Strength Strong.

The CPG committee called for improvement in the study quality of diagnostic accuracy of tests for mTBI in the post-acute period and highlighted the need to identify interactions between cognitive, behavioural, and emotional factors and clinical and demographic factors that may improve diagnostic and prognostic models. The committee noted that further research may be needed to investigate potential differences in blast vs. non-blast mechanism of injury.

CPG mTBI symptom management updates

Symptom management updates to the CPGs were added based on updated literature review and listed below followed by the strength of the recommendation [5].

• Headache treatment should be individualized and tailored to the clinical features and patient preferences: Strength Weak.

• For patients with history of mTBI presenting with functional impairments due to dizziness, disequilibrium and spatial disorientation symptoms, a short-term trial of specific vestibular, visual and proprioceptive therapeutic exercise to assess the individual patient responsiveness to treatment. A prolonged course of therapy in the absence of patient improvement is strongly discouraged: Strength Weak.

• Treatment of sleep disturbance should be individualized and tailored to the clinical features and patient preferences: Strength Weak.

• There is no evidence to suggest for or against the use of any particular modality for the treatment of tinnitus after mTBI: Strength Not Applicable (N/A).

• Recommend against performing comprehensive neuropsychological/cognitive testing during the first 30 days post-injury: Strength Strong.

• Patients with history of mTBI who report cognitive symptoms that do not resolve within 30–90 days and have been refractory to treatment for associated symptoms (e.g. sleep disturbance, headache) be referred as appropriate for a structured cognitive assessment or neuropsychological assessment to determine functional limitations and guide treatment: Strength Weak.

• Patients with history of mTBI presenting with symptoms related to memory, attention or executive function problems that do not resolve within 30–90 days be referred as appropriate to cognitive rehabilitation therapists with expertise in TBI rehabilitation. Consider a short-term trial of specific cognitive rehabilitation to assess the individual patient responsiveness to strategy training, including instruction and practice on use of memory aides to include assistive technology. A prolonged course of therapy in the absence of patient improvement is strongly discouraged: Strength Weak.

• Recommend against routinely offering medications, supplements, nutraceuticals or herbal medicines for ameliorating the neurocognitive effects attributed to mTBI: Strength Weak.

• Recommend assessing patients with symptoms attributed mTBI for psychiatric symptoms and comorbid psychiatric disorders including major depressive disorder, post-traumatic stress, substance use disorders and suicidality. Consult appropriate VA/DoD CPGs for guidelines: Strength Strong.

• Evaluate and manage the presence of psychological or behavioural symptoms following mTBI according to existing evidence-based CPGs and based upon individual factors and the nature and severity of symptoms: Strength Strong.

• Consider and offer as appropriate a primary care symptom-driven approach in the evaluation and management of patient with a history of mTBI and persistent symptoms: Strength weak.

• Patients with symptoms persisting 30–90 days refractory to initial treatment in primary care and significantly impacting activities of daily living should be referred to a TBI specialist: Strength Weak.

• New symptoms developing 30 days after mTBI should be evaluated with a focused diagnostic work-up specific to those symptoms only: Strength Weak.

• There is insufficient evidence to recommend for or against use of interdisciplinary/multidisciplinary teams in management of patients with chronic symptoms attributed to mTBI: Strength N/A.

• There is no evidence to suggest for or against the use of any particular modality for the treatment of visual symptoms such as diplopia, accommodation or convergence disorder, visual tracking deficits and/or photophobia after mTBI: Strength N/A.

• Patients with persistent symptoms that have been refractory to initial psychoeducation and treatment, referral to case managers within the primary care setting to provide additional psychoeducation, case coordination and support: Strength Weak.

Management of symptoms in individuals with mTBI remains symptom-based and guidelines continue to highlight non-pharmacologic interventions. Two of the above recommendations included caveats to measure progress from therapeutic interventions and advised against continuation of therapy without clear benefit from the intervention. Research needs identified by the committee included further study to better understand the effectiveness of non-pharmacologic interventions for potential TBI-related symptoms and improved understanding of sub-groups of patients that are more likely to benefit from these interventions.

TBI psychiatric comorbidity in war zone veterans

In war zones, the same circumstances that elevate risk of TBI (e.g. intensive combat, unexpected IED explosions) are also often associated with extreme psychological stress. Relatedly, many veterans with history of war zone TBI also experience stress-related disorders such as post-traumatic stress disorder (PTSD), and mood and anxiety disorders [8–10]. In some veterans, TBI and other physical injuries associated with the TBI event lead to outcomes (e.g. diminished functioning, chronic pain) that further contribute to psychological distress [11,12]. Similarly, emotional distress may impede optimal recovery from TBI [13,14]. In this section, we consider the clinical management of stress-related psychiatric disorders in veterans who incurred a deployment-related TBI. We focus in particular on treatment of PTSD (the other ‘signature injury’ of OEF/OIF) in veterans with history of mTBI because of the common comorbidity of PTSD and mTBI in war zone veterans. Because diagnostic determinations constitute a preliminary step to treatment, we begin with a brief review of assessment considerations for veterans presenting with possible post-concussive symptoms and a stress-related psychiatric disorder.

Assessment of post-concussive symptoms and stress-related psychiatric disorders

Clinical guidelines exist for assessment of both TBI (reviewed above) and psychiatric comorbidities, such as PTSD, but challenges often arise when assessing comorbid psychiatric disorders in veterans with history of deployment TBI. Threats to diagnostic validity occur both in establishing the trauma (whether brain and/or psychological trauma) [15–17] and at the symptom level [18,19]. Typically, threats in establishing injury/trauma history arise because of factors inherent to war zones and may include lack of witness reports, a chaotic environment that challenges subsequent reconstruction of the event from memory, for mTBI, difficulties discerning immediate symptoms related to an extreme stress reaction (e.g. sudden physiological changes related to a biological survival response) from those related to brain trauma (e.g. transient neural disruption) and for more significant TBI, a failure to encode the injury and events before and/or after it. At the symptom level, challenges reflect the considerable overlap in clinical presentation and subjective complaints (e.g. anxiety, dysphoric symptoms, irritability, sleep disturbance, concentration and memory problems, fatigue and arousal dysregulation) between post-concussive symptoms and stress-related psychiatric disorders, often making symptom attribution difficult. Even methods relying on objective measures such as performance-based neuropsychological testing cannot in isolation reliably differentiate aetiology, as psychiatric disorders are also often associated with neurocognitive performance deficits [20,21].

Certain symptoms (e.g. cognitive impairment, anger control and sleep disturbance) may be treated without regard to aetiology, suggesting on the surface that aetiological attribution may not be important. However, many evidence-based interventions for psychiatric comorbidities such as PTSD depend on establishing a valid diagnosis, as aspects of the interventions (e.g. exposure for PTSD) are tailored to the disorder. Therefore, whereas it may not be necessary or possible to attribute each symptom to a specific aetiology, clinicians must identify whether (and which) psychiatric disorders contribute to the clinical presentation. Although assessment practices for psychiatric comorbidities are beyond the scope of this paper, best practices take into account the challenges listed above, and reflect components such as incorporation of both validated psychometric measures and structured clinical interviews, attention to symptom validity, and consideration of the course and progression of symptoms [22].

Treatment of PTSD and related disorders in veterans with deployment TBI history

Both pharmacological and psychosocial interventions have been used effectively to treat PTSD and other stress-related disorders. We focus on cognitive behavioural therapy (CBT) because CBT with exposure-based (e.g. Prolonged Exposure [PE]) and cognitive (e.g. Cognitive Processing Therapy [CPT]) components have among the strongest evidence bases of treatments for PTSD [23]. CBT is likewise efficacious for non-PTSD trauma-related conditions, such as depression, anxiety and somatoform disorders [24]. Clear, empirically based guidelines for their implementation in veterans with TBI, however, are needed.

Questions about the use of CBT post-TBI typically centre on the cognitive demands (e.g. cognitive flexibility, cognitive inhibition, memory reconstruction and directed attention) of the interventions in the context of possible TBI-related neurocognitive deficits. CBT for trauma-related disorders uses cognitive re-appraisal to address distorted thoughts stemming from the trauma and/or exposes patients within a safe context to their trauma memories and reminders to desensitize them to their fears [25]. CBT also often requires ‘homework’ outside of the therapy session, and therefore the ability to remember to engage in therapeutic activities outside the structure of the clinical encounter [26].

Considerations in implementing CBTs for PTSD and related disorders in veterans with history of TBI can be summarized as follows: (1) the safety and relative effectiveness of the interventions, as compared with their delivery to patients without TBI and (2) whether the interventions, or their delivery, should be modified or augmented with cognitive enhancement strategies.

Safety and effectiveness of CBT with TBI

Preliminary evidence suggests that CBT can reduce post-traumatic acute stress, PTSD symptoms and non-specific post-concussive symptoms in patients with history of mild, moderate and even severe TBI without significant adverse events [27,28,29]. Moreover, veterans with TBI history respond as well to CBT for treatment of PTSD as those without TBI, with effect sizes comparable, or superior, to prior clinical trials [11–13]. In addition to PTSD symptom reduction, both depressive symptoms [28,30,31] and post-concussive symptoms [32] decrease following PTSD-focused CBT interventions in patients with history of TBI. Likewise, CBT has been successfully applied to targeted treatment of a range of other emotional and behavioural sequelae of TBI such as insomnia [33], social anxiety [34,35] and depression [34].

Treatment adherence and minimization of attrition also constitute essential considerations in the appropriateness of any intervention. Adherence to CBT for treatment of PTSD in patients with TBI resembles that found in trauma populations more generally, in which attrition ranges from 0 to 50%. A study specifically examining CPT adherence in an outpatient setting [36] found no significant differences in attrition rates between PTSD patients with mTBI (38.6%) and those without history of TBI (38.0%). Thus, existing evidence, although still preliminary, suggests that CBTs for PTSD and related disorders in patients with TBI are both safe and effective across a range of TBI severities.

Modification, augmentation and adjunctive strategies

Questions have also been raised regarding how, or even whether, to modify PTSD interventions when the clinical presentation includes history of TBI—particularly in veterans expressing current neurocognitive complaints or deficits. Moreover, the term ‘modification’ is ambiguous, interpreted by some to include only delivery-related accommodations not specifically addressed by intervention protocols (e.g. external memory aids) or well within the constraints of individualization allowed by the protocol, but interpreted by others to mean explicit departures from well-articulated manualized parameters that are of central mechanistic significance to the intervention.

A few studies have described accommodations or modifications that were used in their treatment protocols. For example, to compensate for potential TBI deficits in memory, attention and processing speed, Wolf et al. [28] adjusted PE implementation, as clinically indicated, to include (1) memory-enhancing compensatory strategies and devices (e.g. personal digital assistants, mid-week telephone coaching calls), (2) increased structure of session content and (3) longer sessions. Other accommodations to CBT used in TBI patients samples have included the use of handouts, written session summaries, and the simplification and repetition of content [34].

In terms of adjunctive interventions to evidence-based interventions for PTSD and related disorders in veterans with TBI history, cognitive rehabilitation has emerged as a promising possibility. Although cognitive rehabilitation typically targets one or more specific cognitive domains, relatively comprehensive interventions that provide psychoeducation about post-concussive symptoms in addition to cognitive compensatory training (e.g. Cognitive Symptom Management and Rehabilitation Therapy [CogSmart]) have reduced non-specific affective symptoms and improved quality of life in veterans with PTSD and mild to moderate TBI [37] but have not necessarily significantly reduced PTSD symptoms when delivered in isolation of evidence-based PTSD treatments [38]. Cognitive rehabilitation has also been included as a component of intensive in-patient programmes treating patients with PTSD and TBI, but it remains unknown whether cognitive rehabilitation will provide incremental value as an adjunctive treatment.

Discussion

Available medical evidence has been incorporated into TBI CPRs and CPGs. In some areas, the strongest evidence supports against the use of certain modalities or testing. For instance, routine neuropsychological testing within 30 days of injury is not supported by published evidence. In general, recommendations for assessment have the strongest support whereas management recommendations can be more challenging due to frequent comorbidities, particularly mental health issues.

Areas with the weakest evidence/support from the CPG committee include specific targeted interventions for symptoms including sleep, headache, dizziness/disequilibrium, neurocognitive assessment and referral to a TBI specialist. Although many of these recommendations appear to be common clinical practice, the limited evidence does not rise to the level of a strong recommendation. Many recommendations were graded as ‘weak for’ or ‘weak against’. Because randomized controlled trials of TBI interventions may be challenging to perform, the leveraging of electronic health records (EHRs) by VA and DoD to provide real-time evidence based on current practice patterns becomes an important potential source of information. Specifically, harnessing EHR data may help to garner additional evidence of the effectiveness of these interventions provided that objective outcome measures are collected in the EHR and able to connect them to the targeted symptom.

In addition, the strength ratings of several CPG updates were identified as not applicable (N/A) including management recommendations for tinnitus, visual symptoms and recommendations for interdisciplinary care. Again, the current practices for managing these symptoms may be viewed as a common sense approach to TBI management, but the paucity of published evidence limits the strength of their recommended use.

Monitoring implementation and adherence to CPGs and CPRs is also challenging given the nature of the non-specific symptoms following TBI and associated comorbidities. CPGs are currently available within VA’s EHR through a search option that requires extra steps by the front line provider. CPGs should be user-friendly within the EHR to better guide clinical care. If the CPGs were electronically embedded into the EHR, compliance would be measurable and could be studied to better understand barriers and facilitators to implementation.

Finally, another practice component for which the evidence base is still developing is in regard to treatment of common comorbid psychiatric disorders in veterans with history of TBI. In particular, it is yet to be determined whether there is a need to, or incremental value in, modifying or augmenting evidence-based treatments for psychiatric comorbidities, such as PTSD. Further, if determined to be of benefit to veterans with TBI, greater understanding of potentially modifiable components of evidence-based treatments of psychiatric comorbidities is needed. For example, well-meaning clinicians may modify essential components of the treatment rather than just the mode of delivery. Thus, there is a need to identify and clearly differentiate the non-modifiable components of these treatments from components, such as delivery platforms, that may be altered to accommodate cognitive impairment and other potential TBI-related symptoms without reducing the potency of the intervention.

While multiple areas of evidence for TBI assessment and management are needed, the five top research priorities to advance CPGs and best practices identified at the TBI SOTA include:

1. Leverage the EHR to collect data for analysis to study clinical practice (with good metrics) compared to randomized controlled clinical trials.

2. Investigate the extent of CPG implementation and evaluate outcomes. Utilize a performance improvement feedback loop on CPG utilization to providers at the point of service. Further investigation is needed to evaluate the importance of patient education within the CPGs.

3. Study the limitations of modifying/augmenting manualized treatment of TBI and comorbidities including delivery vehicles, motivation and identification of non-modifiable core tenants of the treatment.

4. Utilize knowledge gaps identified in the mTBI CPG updates to promote research priorities in TBI assessment and treatment.

5. Utilize existing data registries to improve continuity of care between DoD and VA.

Summary

Care for service members and veterans with a history of TBI remains a priority for DoD and VA. CPRs and CPGs have been developed to promote evidence-based care for residual symptoms following TBI and treatment for associated comorbidities. Remaining gaps in treatment knowledge will require further research to answer. Potential ways to address these gaps include leveraging large data sources, evaluating the extent of CPG utilization in current care, prioritizing research funding to address knowledge gaps, and further study of existing treatments to identify core concepts of the interventions that cannot be modified. As further knowledge of effective treatments for symptoms following TBI and other potential comorbid conditions develops, CPR and CPG updates will be required.

Declaration of interest

The authors report no declarations of interest.